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Carriers
Can't Punish You For Self-Disclosing Problems But
There's A Catch -- Don't go straight to the carriers if
the problem looks serious

The
Medicare Modernization Act contains one welcome provision
that prevents your carrier from putting you on prepayment
review if you come forward voluntarily to disclose a billing
problem. Or does it?

But
now the Centers for Medicare & Medicaid Services has
carved out an exception to that rule which the carriers
could drive an 18-wheeler through. If you self-disclose
an improper business practice, "and the contractor
determines that there is a sustained or high level of payment
error," then the carrier can go ahead and put you on
prepayment review anyway, according to Transmittal 100-08
(Change Request 3569).

Still,
the change is better than nothing, says attorney Lester
Perling with Broad & Cassell in Fort Lauderdale, FL.
"The carriers previously had a totally free hand in
putting a provider on prepayment review," he notes.
Now, they have to show a sustained pattern of overpayment,
which CMS fails to define.

Most
likely if you come forward with a couple of overpayments
worth $500, you're safe, but if you disclose that all of
your evaluation & management visits have been upcoded
two levels for the past year, you could be in for some review,
Perling says.

Fortunately
for providers, the carriers aren't fans of prepayment review,
because they don't get paid any more money for doing it.
And it's a lot of work to move a provider from electronic
to paper claims and pay someone to sift through all of them,
Perling notes.